THE DAVE LAWRENCE WAKEFIELD SCHEME  

ACCEPTANCE FORM 

1.     I would like to take part in the Dave Lawrence Wakefield scheme. 

2. I have read, understood and agree with the latest terms and conditions, and by signing this acceptance form agree to be bound by them, and to any future amendments that are voted in. 

3. I fully understand that it is my responsibility to return and update the acceptance form as and when necessary.

                                                                                                                                                     4. I am aware that a claim will only be accepted if my Wakefield DIA subscriptions are up to date.   

5. I understand that if I wish to make a claim it must be backed up by a letter or sick note from

the Hospital or GP.             

6. My entitlement to any moneys due ceases after six payments/year, or when I can return to work whichever is soonest.

7. I agree to pay £5.00/week/claim for all legitimate claims.

8. I must disclose any pre-existing conditions that have stopped me working for more than 2weeks in the previous 12 months. (These will not be covered for the first 12 months) 

                Pre-existing conditions………………………………………………………………………….

                …………………………………………………………………………………………………..                                                                                                                           

Name..............................................................................................................................................                          

Address..........................................................................................................................................                                    

.......................................................................................................................................................                                                

........................................................................................Postcode................................................. 

Tel no.......................................................................Mobile...........................................................

Next of kin………………………………………………………………………………………. 

E-mail address................................................................................................................................ 

Signed............................................................................................   Dated.....................................

Witness................................................................................................ 

(Must be witnessed by a WDIA committee member) 

Sign and return to- SCHEME MANAGER 

                                                                                ROY MITCHELL

                                                                                   1 PERTH DRIVE,                                                                                                                                                                                                                           WAKEFIELD,                                                                                        

                                                                                        WF3 1TZ

                                                                                                TEL 01132528621

                                                                                                                                                JUNE 09